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1.
JAMA Netw Open ; 4(3): e212618, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33755167

RESUMO

Importance: This study assesses the role of telehealth in the delivery of care at the start of the COVID-19 pandemic. Objectives: To document patterns and costs of ambulatory care in the US before and during the initial stage of the pandemic and to assess how patient, practitioner, community, and COVID-19-related factors are associated with telehealth adoption. Design, Setting, and Participants: This is a cohort study of working-age persons continuously enrolled in private health plans from March 2019 through June 2020. The comparison periods were March to June in 2019 and 2020. Claims data files were provided by Blue Health Intelligence, an independent licensee of the Blue Cross and Blue Shield Association. Data analysis was performed from June to October 2020. Main Outcomes and Measures: Ambulatory encounters (in-person and telehealth) and allowed charges, stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee's zip code. Results: A total of 36 568 010 individuals (mean [SD] age, 35.71 [18.77] years; 18 466 557 female individuals [50.5%]) were included in the analysis. In-person contacts decreased by 37% (from 1.63 to 1.02 contacts per enrollee) from 2019 to 2020. During 2020, telehealth visits (0.32 visit per person) accounted for 23.6% of all interactions compared with 0.3% of contacts in 2019. When these virtual contacts were added, the overall COVID-19 era patient and practitioner visit rate was 18% lower than that in 2019 (1.34 vs 1.64 visits per person). Behavioral health encounters were far more likely than medical contacts to take place virtually (46.1% vs 22.1%). COVID-19 prevalence in an area was associated with higher use of telehealth; patients from areas within the top quintile of COVID-19 prevalence during the week of their encounter were 1.34 times more likely to have a telehealth visit compared with those in the lowest quintile (the reference category). Persons living in areas with limited social resources were less likely to use telehealth (most vs least socially advantaged neighborhoods, 27.4% vs 19.9% usage rates). Per enrollee medical care costs decreased by 15% between 2019 and 2020 (from $358.32 to $306.04 per person per month). During 2020, those with 1 or more COVID-19-related service (1 470 721 members) had more than 3 times the medical costs ($1701 vs $544 per member per month) than those without COVID-19-related services. Persons with 1 or more telehealth visits in 2020 had considerably higher costs than persons having only in-person ambulatory contacts ($2214.10 vs $1337.78 for the COVID-19-related subgroup and $735.87 vs $456.41 for the non-COVID-19 subgroup). Conclusions and Relevance: This study of a large cohort of patients enrolled in US health plans documented patterns of care at the onset of COVID-19. The findings are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the pandemic and afterward.


Assuntos
Assistência Ambulatorial , Padrões de Prática Médica , Telemedicina , Adulto , Assistência Ambulatorial/economia , Assistência Ambulatorial/métodos , Assistência Ambulatorial/estatística & dados numéricos , /prevenção & controle , Estudos de Coortes , Custos e Análise de Custo , Feminino , Humanos , Controle de Infecções/métodos , Seguro Saúde/estatística & dados numéricos , Masculino , Inovação Organizacional/economia , Padrões de Prática Médica/economia , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/estatística & dados numéricos , Telemedicina/economia , Telemedicina/organização & administração , Telemedicina/estatística & dados numéricos , Estados Unidos/epidemiologia
3.
J Med Internet Res ; 23(3): e26516, 2021 03 03.
Artigo em Inglês | MEDLINE | ID: mdl-33656440

RESUMO

BACKGROUND: The COVID-19 pandemic has caused patients to avoid seeking medical care. Provision of telemonitoring programs in addition to usual care has demonstrated improved effectiveness in managing patients with heart failure (HF). OBJECTIVE: We aimed to examine the potential clinical and health economic outcomes of a telemonitoring program for management of patients with HF during the COVID-19 pandemic from the perspective of health care providers in Hong Kong. METHODS: A Markov model was designed to compare the outcomes of a care under COVID-19 (CUC) group and a telemonitoring plus CUC group (telemonitoring group) in a hypothetical cohort of older patients with HF in Hong Kong. The model outcome measures were direct medical cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the model assumptions and the robustness of the base-case results. RESULTS: In the base-case analysis, the telemonitoring group showed a higher QALY gain (1.9007) at a higher cost (US $15,888) compared to the CUC group (1.8345 QALYs at US $15,603). Adopting US $48,937/QALY (1 × the gross domestic product per capita of Hong Kong) as the willingness-to-pay threshold, telemonitoring was accepted as a highly cost-effective strategy, with an incremental cost-effective ratio of US $4292/QALY. No threshold value was identified in the deterministic sensitivity analysis. In the probabilistic sensitivity analysis, telemonitoring was accepted as cost-effective in 99.22% of 10,000 Monte Carlo simulations. CONCLUSIONS: Compared to the current outpatient care alone under the COVID-19 pandemic, the addition of telemonitoring-mediated management to the current care for patients with HF appears to be a highly cost-effective strategy from the perspective of health care providers in Hong Kong.


Assuntos
Assistência Ambulatorial , Análise de Dados , Insuficiência Cardíaca/epidemiologia , Método de Monte Carlo , Telemedicina/economia , Telemedicina/métodos , Assistência Ambulatorial/economia , Assistência Ambulatorial/métodos , Estudos de Coortes , Análise Custo-Benefício , Hong Kong/epidemiologia , Humanos , Cadeias de Markov , Pandemias , Anos de Vida Ajustados por Qualidade de Vida
4.
Eur J Vasc Endovasc Surg ; 61(3): 447-455, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33414066

RESUMO

OBJECTIVE: The AMBUVASC trial evaluated the cost effectiveness of outpatient vs. inpatient hospitalisation for endovascular repair of lower extremity arterial disease (LEAD). METHODS: AMBUVASC was a national multicentre, prospective, randomised controlled trial conducted in nine public and two private French centres. The primary endpoint was the incremental cost effectiveness ratio (ICER), defined by cost per quality adjusted life year (QALY). Analysis was conducted from a societal perspective, excluding indirect costs, and considering a one month time horizon. RESULTS: From 16 February 2016 to 29 May 2017, 160 patients were randomised (80 per group). A modified intention to treat analysis was performed with 153 patients (outpatient hospitalisation: n = 76; inpatient hospitalisation: n = 77). The patients mainly presented intermittent claudication (outpatient arm: 97%; inpatient arm: 92%). Rates of peri-operative complications were 20% (15 events) and 18% (14 events) for the outpatient and inpatient arms respectively (p = .81). Overall costs (difference: €187.83; 95% confidence interval [CI] -275.68-651.34) and QALYs (difference: 0.00277; 95% CI -0.00237 - 0.00791) were higher for outpatients due to more re-admissions than the inpatient arm. The mean ICER was €67 741 per QALY gained for the base case analysis with missing data imputed using multiple imputation by predictive mean matching. The outpatient procedure was not cost effective for a willingness to pay of €50 000 per QALY and the probability of being cost effective was only 59% for a €100 000/QALY threshold. CONCLUSION: Outpatient hospitalisation is not cost effective compared with inpatient hospitalisation for endovascular repair of patients with claudication at a €50 000/QALY threshold.


Assuntos
Assistência Ambulatorial/economia , Procedimentos Endovasculares/economia , Custos Hospitalares , Hospitalização/economia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/economia , Doença Arterial Periférica/terapia , Idoso , Redução de Custos , Análise Custo-Benefício , Procedimentos Endovasculares/efeitos adversos , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Estudos Prospectivos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento
5.
Artigo em Inglês | MEDLINE | ID: mdl-33093768

RESUMO

Background: Sarcoidosis is a rare, chronic systemic disease. Earlier data (2006-2010) suggest that the incidence of pulmonary sarcoidosis in Silesian voivodeship increased, however there is no current data on other clinical forms of the disease. Objectives: The aim of presented study was an analysis of the actual epidemiological situation of sarcoidosis with simultaneous estimation of treatment cost financed from public funds. Methods: Epidemiological descriptive study concerned registered cases of sarcoidosis diagnosed in adult inhabitants of the Silesian voivodeship in years 2011-2015. Secondary epidemiological data on the main diagnosis and co-morbidity were obtained from the National Health Fund (NFZ) database in Katowice. Territorial and temporal variability of standardized incidence rates were analysed with simultaneous estimation of treatment costs reimbursed from the state budget. Results: Pulmonary sarcoidosis was the most frequently registered clinical form of such disease in the Silesian voivodeship (65% of total cases). The highest number of cases was diagnosed in the age 35-54 years, frequently in men than in women. Significantly decrease of the standardized incidence of sarcoidosis noticed between 2011 and 2015 is related with observed lower number of total cases of pulmonary disease. Observed territorial variability of the sarcoidosis incidence requires future, well-planned studies. The annual average direct cost of sarcoidosis treatment is high and exceed 538 EUR per patient. Conclusions: It was confirmed that sarcoidosis in the Silesian Voivodeship is a rare disease, however reimbursed direct costs of treatment remains very high. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 43-52).


Assuntos
Custos de Cuidados de Saúde , Sarcoidose Pulmonar , Adulto , Idoso , Assistência Ambulatorial/economia , Comorbidade , Efeitos Psicossociais da Doença , Feminino , Custos Hospitalares , Humanos , Incidência , Reembolso de Seguro de Saúde/economia , Masculino , Pessoa de Meia-Idade , Polônia/epidemiologia , Fatores de Risco , Sarcoidose Pulmonar/diagnóstico , Sarcoidose Pulmonar/economia , Sarcoidose Pulmonar/epidemiologia , Sarcoidose Pulmonar/terapia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
6.
Cochrane Database Syst Rev ; 9: CD012780, 2020 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-32996586

RESUMO

BACKGROUND: Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously. OBJECTIVES: To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families. SEARCH METHODS: We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available. MAIN RESULTS: We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I2 = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I2 = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I2 = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I2 = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I2 = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision. AUTHORS' CONCLUSIONS: Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.


Assuntos
Cuidadores/estatística & dados numéricos , Serviços Hospitalares de Assistência Domiciliar/economia , Cuidados Paliativos/economia , Cuidados Paliativos/métodos , Assistência Terminal/economia , Assistência Terminal/métodos , Assistência Ambulatorial/economia , Viés , Cuidadores/psicologia , Análise Custo-Benefício , Família , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Hospitalização/economia , Humanos , Neoplasias/mortalidade , Neoplasias/terapia , Manejo da Dor/estatística & dados numéricos , Satisfação do Paciente , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Avaliação de Sintomas/estatística & dados numéricos
7.
PLoS One ; 15(9): e0238980, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915916

RESUMO

Hypertension remains the leading risk factor for death and disability in China, and the ability of hypertensive patients to pay for outpatient care and medication has become a critical issue. To report the effect of an outpatient copayment scheme on health outcomes of hypertensive adults in a community-managed population in Xinjiang, we compared changes in outcomes between insured and uninsured groups from baseline to the first follow-up appointment in a community-managed hypertensive population and evaluated these changes based on propensity score matching and the difference-in-difference method. A total of 1,095 individuals in a community-managed hypertension population were selected for investigation at baseline, among which 805 (73.5%) had follow-up data and 749 (68.4%) were included in our analysis. After accounting for the self-reported severity of hypertension and individual characteristics, there were statistically significant improvements in drug treatment of hypertension and self-reported health. We also found increases in drug treatment for hypertension between groups, after correcting for confounding variables (Odds Ratio, OR 8.05, 95% Confidence interval, CI, 1.31-49.35), and in self-reported health between groups after correcting confounders (OR 1.96, 95% CI, 1.12 to 3.42). Adjusted estimates (confounding variables) were corrected for age, sex, income, marital status, education level, employment, family size, self-reported severity of hypertension, course of hypertension, and number of medications. As a result, decreased outpatient copayment was associated with an increase in antihypertensive treatment coverage, and an improvement in self-reported health among community-managed hypertensive populations in Xinjiang, China.


Assuntos
Assistência Ambulatorial/economia , Gastos em Saúde , Hipertensão/tratamento farmacológico , Hipertensão/economia , Idoso , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , China , Serviços de Saúde Comunitária/economia , Feminino , Humanos , Hipertensão/fisiopatologia , Masculino , Avaliação de Resultados em Cuidados de Saúde , Pontuação de Propensão , Qualidade de Vida , Autorrelato , Inquéritos e Questionários , Resultado do Tratamento
8.
J Am Acad Orthop Surg ; 28(20): e900-e909, 2020 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-32826663

RESUMO

As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.


Assuntos
Assistência Ambulatorial/métodos , Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Alta do Paciente , Seleção de Pacientes , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Analgesia/métodos , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Redução de Custos , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Educação de Pacientes como Assunto , Segurança do Paciente , Fatores de Risco
9.
Med Care ; 58(10): 919-926, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32842044

RESUMO

BACKGROUND: Relative costs of care among treatment options for opioid use disorder (OUD) are unknown. METHODS: We identified a cohort of 40,885 individuals with a new diagnosis of OUD in a large national de-identified claims database covering commercially insured and Medicare Advantage enrollees. We assigned individuals to 1 of 6 mutually exclusive initial treatment pathways: (1) Inpatient Detox/Rehabilitation Treatment Center; (2) Behavioral Health Intensive, intensive outpatient or Partial Hospitalization Services; (3) Methadone or Buprenorphine; (4) Naltrexone; (5) Behavioral Health Outpatient Services, or; (6) No Treatment. We assessed total costs of care in the initial 90 day treatment period for each strategy using a differences in differences approach controlling for baseline costs. RESULTS: Within 90 days of diagnosis, 94.8% of individuals received treatment, with the initial treatments being: 15.8% for Inpatient Detox/Rehabilitation Treatment Center, 4.8% for Behavioral Health Intensive, Intensive Outpatient or Partial Hospitalization Services, 12.5% for buprenorphine/methadone, 2.4% for naltrexone, and 59.3% for Behavioral Health Outpatient Services. Average unadjusted costs increased from $3250 per member per month (SD $7846) at baseline to $5047 per member per month (SD $11,856) in the 90 day follow-up period. Compared with no treatment, initial 90 day costs were lower for buprenorphine/methadone [Adjusted Difference in Differences Cost Ratio (ADIDCR) 0.65; 95% confidence interval (CI), 0.52-0.80], naltrexone (ADIDCR 0.53; 95% CI, 0.42-0.67), and behavioral health outpatient (ADIDCR 0.54; 95% CI, 0.44-0.66). Costs were higher for inpatient detox (ADIDCR 2.30; 95% CI, 1.88-2.83). CONCLUSION: Improving health system capacity and insurance coverage and incentives for outpatient management of OUD may reduce health care costs.


Assuntos
Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/reabilitação , Adolescente , Adulto , Idoso , Assistência Ambulatorial/economia , Terapia Comportamental/economia , Buprenorfina/uso terapêutico , Estudos de Coortes , Feminino , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Masculino , Medicare , Metadona/uso terapêutico , Pessoa de Meia-Idade , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Estudos Retrospectivos , Estados Unidos
10.
Am J Gastroenterol ; 115(10): 1698-1706, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32701731

RESUMO

INTRODUCTION: Biologic agents including infliximab are effective but costly therapies in the management of inflammatory bowel disease (IBD). Home infliximab infusions are increasingly payer-mandated to minimize infusion-related costs. This study aimed to compare biologic medication use, health outcomes, and overall cost of care for adult and pediatric patients with IBD receiving home vs office- vs hospital-based infliximab infusions. METHODS: Longitudinal patient data were obtained from the Optum Clinformatics Data Mart. The analysis considered all patients with IBD who received infliximab from 2003 to 2016. Primary outcomes included nonadherence (≥2 infliximab infusions over 10 weeks apart in 1 year) and discontinuation of infliximab. Secondary outcomes included outpatient corticosteroid use, follow-up visits, emergency room visits, hospitalizations, surgeries, and cost outcomes (out-of-pocket costs and annual overall cost of care). RESULTS: There were 27,396 patients with IBD (1,839 pediatric patients). Overall, 5.7% of patients used home infliximab infusions. These patients were more likely to be nonadherent compared with both office-based (22.2% vs 19.8%; P = .044) and hospital-based infusions (22.2% vs 21.2%; P < .001). They were also more likely to discontinue infliximab compared with office-based (44.7% vs 33.7%; P < .001) or hospital-based (44.7% vs 33.4%; P < .001) infusions. On Kaplan-Meier analysis, the probabilities of remaining on infliximab by day 200 of therapy were 64.4%, 74.2%, and 79.3% for home-, hospital-, and office-based infusions, respectively (P < .001). Home infliximab patients had the highest corticosteroid use (cumulative corticosteroid days after IBD diagnosis: home based, 238.2; office based, 189.7; and hospital based, 208.5; P < .001) and the fewest follow-up visits. Home infusions did not decrease overall annual care costs compared with office infusions ($49,149 vs $43,466, P < .001). DISCUSSION: In this analysis, home infliximab infusions for patients with IBD were associated with suboptimal outcomes including higher rates of nonadherence and discontinuation of infliximab. Home infusions did not result in significant cost savings compared with office infusions.


Assuntos
Assistência Ambulatorial/métodos , Terapia por Infusões no Domicílio/métodos , Doenças Inflamatórias Intestinais/tratamento farmacológico , Infliximab/uso terapêutico , Adesão à Medicação/estatística & dados numéricos , Inibidores do Fator de Necrose Tumoral/uso terapêutico , Adolescente , Corticosteroides/uso terapêutico , Adulto , Idoso , Assistência Ambulatorial/economia , Criança , Estudos de Coortes , Colite Ulcerativa/tratamento farmacológico , Redução de Custos , Doença de Crohn/tratamento farmacológico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Gastos em Saúde , Terapia por Infusões no Domicílio/economia , Hospitalização/estatística & dados numéricos , Humanos , Infusões Intravenosas , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/estatística & dados numéricos , Consultórios Médicos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
11.
Reg Anesth Pain Med ; 45(8): 579-585, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32475827

RESUMO

The COVID-19 pandemic has resulted in significant clinical and economic consequences for medical practices of all specialties across the nation. Although the clinical implications are of the utmost importance, the economic consequences have also been serious and resulted in substantial damage to the US healthcare system, including pain practices. Outpatient pain practices have had to significantly change their clinical care pathways, including the incorporation of telemedicine. Elective medical and interventional care has been postponed. For the most part, ambulatory surgical centers have had to cease operations. As patient volumes have decreased for non-emergent elective care, the financial indicators have deteriorated. This review article will provide insight into solutions to mitigate the clinical and economic challenges induced by COVID-19. Undoubtedly, the COVID-19 pandemic will have short-term and long-term implications for all medical practices and facilities. In order to survive, medical practices will need dynamic, operational, and creative strategic plans to mitigate the disruption in medical care and pathways for successful reintegration of clinical and surgical practice.


Assuntos
Assistência Ambulatorial/economia , Infecções por Coronavirus/economia , Infecções por Coronavirus/terapia , Manejo da Dor/métodos , Pandemias/economia , Pneumonia Viral/economia , Pneumonia Viral/terapia , Assistência Ambulatorial/estatística & dados numéricos , Humanos , Seguro Saúde , Telemedicina , Estados Unidos
12.
Diabetes Metab Syndr ; 14(5): 731-732, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32473905

RESUMO

BACKGROUND AND AIMS: Diabetes mellitus (DM) is one of the most critical risk factors for complications and death in COVID-19 patients. The present study aims to highlight challenges in the management of diabetic patients during the COVID-19 outbreak in developing countries. METHODS: We reviewed the literature to obtain information about diabetic care during the Covid-19 crisis. We also seek opinions of clinicians working in undeveloped countries. RESULTS: Current challenges faced by clinicians in the management of diabetic patients in developing countries are as follows: lack of preventive measures, inadequate number of visits, loss of the traditional method of communication with the patient, shortage of medications, impaired routine diabetic care, and absence of telehealth services. CONCLUSIONS: Developing countries are faced with many challenges in diabetes management due to a lack of resources.


Assuntos
Infecções por Coronavirus/epidemiologia , Países em Desenvolvimento , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Pneumonia Viral/epidemiologia , Assistência Ambulatorial/economia , Assistência Ambulatorial/normas , Assistência Ambulatorial/estatística & dados numéricos , Betacoronavirus/fisiologia , Infecções por Coronavirus/complicações , Países em Desenvolvimento/economia , Países em Desenvolvimento/estatística & dados numéricos , Diabetes Mellitus/economia , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Incidência , Pandemias , Pneumonia Viral/complicações , Fatores de Risco , Telemedicina/economia , Telemedicina/métodos
13.
PLoS One ; 15(5): e0232129, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32379783

RESUMO

BACKGROUND: In China, the disease burden of cervical cancer remains substantial. Human papillomavirus (HPV) vaccines are expensive and not yet centrally funded. To inform immunization policy, understanding the economic burden of the disease is necessary. This study adopted a societal perspective and investigated costs and quality of life changes associated with cervical cancer from diagnosis to one year after final discharge in Henan province, China. METHODS: Inpatient records of cervical cancer patients admitted to the largest cancer hospital in Henan province between Jan. 2017 and Dec. 2018 were extracted. A telephone interview with four modules was conducted in Jun.-Jul. 2019 with a 40% random draw of patients to obtain direct non-medical costs and indirect costs associated with inpatients, costs associated with outpatient visits, and changes in quality of life status using the EQ-5D-5L instrument. Direct medical expenditures were converted to opportunity costs of care using cost-to-charge ratios obtained from hospital financial reports. For each clinical stage (IA-IV), total costs per case from diagnosis to one year after final discharge were extrapolated based on inpatient records, responses to the telephone interview, and recommendation on outpatient follow-ups by Chinese cervical cancer treatment guidelines. Loss in quality-adjusted life years was obtained using the 'under the curve' method and regression predictions. RESULTS: A total of 3,506 inpatient records from 1,323 patients were obtained. Among 541 randomly selected patients, 309 completed at least one module of the telephone interview. The average total costs per case associated with cervical cancer from diagnosis to one year after final discharge ranged from $8,066-$22,888 (in 2018 US Dollar) and the quality-adjusted life years loss varied from 0.05-0.26 for IA-IV patients. CONCLUSIONS: The economic burden associated with cervical cancer is substantial in Henan province. Our study provided important baseline information for cost-effectiveness analysis of HPV immunization program in China.


Assuntos
Vacinas contra Papillomavirus/economia , Neoplasias do Colo do Útero/economia , Adulto , Assistência Ambulatorial/economia , China/epidemiologia , Efeitos Psicossociais da Doença , Análise Custo-Benefício/métodos , Feminino , Gastos em Saúde , Hospitalização/economia , Humanos , Pacientes Internados , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Qualidade de Vida/psicologia , Anos de Vida Ajustados por Qualidade de Vida , Estudos Retrospectivos , Vacinação/economia
14.
Z Gastroenterol ; 58(4): 364-372, 2020 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-32353889

RESUMO

INTRODUCTION: Short-bowel-syndrome (SBS) is an often chronic disease with high morbidity. The aim of this study was to evaluate the complexity of SBS treatment and the economic burden on a treating hospital. METHODS: Anonymized data of eleven consecutive SBS patients from the University Hospital of Bonn were included. Parameters of medical resources were considered for year of diagnosis (YOD) and a follow-up (FU) period of three years. Subsequently, costs were evaluated according to the corresponding catalogues. RESULTS: Median inpatient days were 96 days in YOD and decreased to three days in the third year of FU. Median cost of inpatient treatment decreased from approximately 84 500 € auf 3200 €. While major visceral surgery was usually required in the YOD, catheter-associated interventions dominated during further FU. Actual reimbursement according to the G-DRG covered approximately 50 % of inpatient treatment cost, for outpatient care only est. 16.5 % of costs were covered. Annual costs for medication, parenteral nutrition and GLP-2-analogon treatment added up to 6752 €, 48 485 € and 138 442 €, respectively. CONCLUSIONS: The interdisciplinary medical care of SBS-patients is resource-intensive and expensive. The required treatment shifts from the in- to the outpatient sector. Both settings are at present not adequately reimbursed. Hence, this imbalance may endanger adequate care for SBS-patients in the future in times of economic rationale. In concordance with other rare disease management programs, additional measures are needed to provide and improve interdisciplinary treatment of SBS.


Assuntos
Assistência Ambulatorial/economia , Custos de Cuidados de Saúde/normas , Hospitalização/economia , Equipe de Assistência ao Paciente , Síndrome do Intestino Curto , Assistência Ambulatorial/estatística & dados numéricos , Efeitos Psicossociais da Doença , Alemanha , Hospitalização/estatística & dados numéricos , Humanos
16.
Curr Cardiol Rep ; 22(6): 42, 2020 05 19.
Artigo em Inglês | MEDLINE | ID: mdl-32430629

RESUMO

PURPOSE OF REVIEW: Shorter hospital stay after percutaneous coronary intervention (PCI) can provide economic advantage. Same-day discharge (SDD) after transradial PCI is thought to reduce the cost of care while maintaining the quality and safety. This review summarizes the current knowledge of the benefits and safety of this concept. RECENT FINDINGS: Increase in rate of transradial PCI over the last two decades has resulted in recent growth in rate of acceptance of SDD after a successful procedure. SDD is shown to result in savings of $3500 to $5200 per procedure with comparable adverse event rate of traditional discharge processes. SDD after PCI is shown to be safe and results in cost advantage maintaining the safety profile. The acceptance rate of SDD is still not optimum, and further market penetration of SDD practice would be achieved only if the institutional and operator preference barriers are addressed.


Assuntos
Assistência Ambulatorial/economia , Procedimentos Cirúrgicos Eletivos/economia , Alta do Paciente/economia , Intervenção Coronária Percutânea/economia , Redução de Custos , Análise Custo-Benefício , Humanos , Tempo de Internação/economia , Alta do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/estatística & dados numéricos , Artéria Radial , Stents , Fatores de Tempo , Resultado do Tratamento
17.
J Surg Res ; 254: 197-205, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32450421

RESUMO

BACKGROUND: Negative pressure wound therapy (NPWT) is commonly used to manage complex wounds in the pediatric population. With recently developed portable NPWT devices, providers have the opportunity to transition NPWT to the outpatient setting. However, there are no studies describing outpatient NPWT in pediatric patients. Therefore, the purpose of our study was to leverage a population-level analysis to advance our current knowledge about outpatient NPWT use in pediatric patients. MATERIALS AND METHODS: We analyzed the Truven Health Analytics MarketScan Commercial Claims Database from 2006 to 2014 to identify children treated with NPWT. We compared patient characteristics, indications, complications before and after NPWT, health care utilization within 30 d of NPWT initiation, and health care cost profile of patients treated with NPWT primarily as outpatients versus inpatients. Outpatient NPWT was defined as patients with ≤50% of NPWT coded during an inpatient hospitalization, whereas inpatient NPWT was defined as patients with >50% of NPWT. RESULTS: We identified 3184 patients (1621 inpatients and 1563 outpatients) aged 0-17 y, who were treated with NPWT from 2006 to 2014. Outpatient NPWT was implemented across multiple ages, comorbidities, and indications, with a low complication rate (2.4%). After controlling for hematologic comorbidity and indications, outpatient NPWT was associated with lower risk of complications (odds ratio: 0.57, 95% confidence interval 0.38-0.86) and lower median total costs ($5602.03) compared with inpatient ($15,233.21) therapy. CONCLUSIONS: Outpatient NPWT management in pediatric patients was associated with low complication rates. Additional studies are necessary to determine the most overall cost-effective treatment setting for NPWT in the pediatric population.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Tratamento de Ferimentos com Pressão Negativa/enfermagem , Tratamento de Ferimentos com Pressão Negativa/estatística & dados numéricos , Adolescente , Assistência Ambulatorial/economia , Criança , Pré-Escolar , Feminino , Hospitalização/economia , Humanos , Lactente , Masculino , Tratamento de Ferimentos com Pressão Negativa/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa/economia , Estudos Retrospectivos
18.
Nutr Metab Cardiovasc Dis ; 30(6): 1014-1022, 2020 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-32423665

RESUMO

BACKGROUND AND AIMS: Nonalcoholic steatohepatitis (NASH) may progress to advanced liver disease (AdvLD). This study characterized comorbidities, healthcare resource utilization (HCRU) and associated costs among hospitalized patients with AdvLD due to NASH in Italy. METHODS AND RESULTS: Adult nonalcoholic fatty liver disease (NAFLD)/NASH patients from 2011 to 2017 were identified from administrative databases of Italian local health units using ICD-9-CM codes. Development of compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), or liver transplant (LT) was identified using first diagnosis date for each severity cohort (index-date). Patients progressing to multiple disease stages were included in >1 cohort. Patients were followed from index-date until the earliest of disease progression, end of coverage, death, or end of study. Within each cohort, per member per month values were annualized to calculate all-cause HCRU or costs(€) in 2017. Of the 9,729 hospitalized NAFLD/NASH patients identified, 97% were without AdvLD, 1.3% had CC, 3.1% DCC, 0.8% HCC, 0.1% LT. Comorbidity burden was high across all cohorts. Mean annual number of inpatient services was greater in patients with AdvLD than without AdvLD. Similar trends were observed in outpatient visits and pharmacy fills. Mean total annual costs increased with disease severity, driven primarily by inpatient services costs. CONCLUSION: NAFLD/NASH patients in Italy have high comorbidity burden. AdvLD patients had significantly higher costs. The higher prevalence of DCC compared to CC in this population may suggest challenges of effectively screening and identifying NAFLD/NASH patients. Early identification and effective management are needed to reduce risk of disease progression and subsequent HCRU and costs.


Assuntos
Recursos em Saúde/economia , Custos Hospitalares , Hepatopatia Gordurosa não Alcoólica/economia , Hepatopatia Gordurosa não Alcoólica/terapia , Demandas Administrativas em Assistência à Saúde , Adolescente , Adulto , Idoso , Assistência Ambulatorial/economia , Carcinoma Hepatocelular/economia , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/terapia , Comorbidade , Bases de Dados Factuais , Progressão da Doença , Custos de Medicamentos , Feminino , Recursos em Saúde/tendências , Custos Hospitalares/tendências , Humanos , Itália/epidemiologia , Cirrose Hepática/economia , Cirrose Hepática/epidemiologia , Cirrose Hepática/terapia , Neoplasias Hepáticas/economia , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/terapia , Transplante de Fígado/economia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/diagnóstico , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Admissão do Paciente/economia , Prevalência , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Adulto Jovem
19.
Am J Ophthalmol ; 218: 156-163, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32446736

RESUMO

PURPOSE: The purpose was to assess differences in outpatient ophthalmologic usage based on patient characteristics such as race/ethnicity, income, insurance type, geographical region, and educational attainment. DESIGN: Retrospective cross-sectional study. METHODS: The Medical Expenditure Panel Survey (MEPS) is a nationally representative data set for the noninstitutionalized population cosponsored by the Agency for Healthcare Research. This study involved 183,054 MEPS respondents from 2007 to 2015. Primary outcome measure was patient utilization of outpatient ophthalmologic care. Secondary outcome measure was annual health care use and costs by patients in outpatient, inpatient, and the emergency department settings based on race. RESULTS: Overall, 21,673 participants self-reported an ophthalmologic condition, and 12,462 had at least 1 outpatient ophthalmologic visit. Hispanic (adjusted odds ratio [aOR] 0.72; P < .001) and black patients (aOR 0.74; P < .001) had fewer outpatient visits than their non-Hispanic white counterparts. Uninsured (aOR 0.41; P = .009) and Medicare/Medicaid (aOR 0.92; P < .001) patients had less outpatient care than their privately insured counterparts. Increasing income and education was associated with higher outpatient ophthalmologic care utilization. In the emergency department, non-Hispanic white patients had the least encounters (1.1 per 100 patients) and highest costs ($25,314.05) when compared to non-Hispanic black patients (3.2 encounters per 100 patients and $10,780.22 respectively) and Hispanic patients (2.2 encounters per 100 patients and $9,837.03 respectively). CONCLUSIONS: This study's findings demonstrate differences in outpatient ophthalmologic utilization based on demographic and socioeconomic characteristics. Concurrently, minority Americans had more ophthalmic emergency department visits but lower cost per visit. There is a need to further characterize these differences to predict future ophthalmologic care needs.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Oftalmologia/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Classe Social , Adolescente , Adulto , Idoso , Assistência Ambulatorial/economia , Criança , Estudos Transversais , Feminino , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Oftalmologia/economia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
20.
BMC Health Serv Res ; 20(1): 379, 2020 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-32375758

RESUMO

BACKGROUND: The theory of equality of opportunity attributes total inequality to effort levels and circumstance factors. Inequality attributable to circumstance is defined as inequality of opportunity (IOp), namely inequity. Many studies have been pursued in this area but few concerning health care, especially in China. Despite Chinese health system reforms, healthcare inequity remains. This study explores the extent and sources of IOp in outpatient and inpatient expenditures in China. METHODS: We used three waves (2011, 2013 and 2015) of data from the China Health and Retirement Longitudinal Study that offer a nationally representative sample of Chinese residents aged 45 and older. Based on a pooled regression model, we estimated the contribution of circumstance factors to the inequality in outpatient and inpatient expenditures by defining a counterfactual distribution. The "circumstance-free effort" was introduced to deal with the correlation between circumstance and effort. RESULTS: We report a decline in inequity from 2011 to 2015, and the IOp ratio to total inequality in outpatient and inpatient expenditures decreased 9.4% (from 28.6 to 25.9%) and 3.3% (from 49.1 to 47.5%), respectively. Social background, medical supply-side factors, including the type of basic medical insurance, region and community medical resources were important sources of IOp in outpatient and inpatient expenditures. CONCLUSIONS: These findings provide information on which to base policies designed to reduce inequity in healthcare expenditures. It is necessary to transfer more subsidies to the New Co-operative Medical System, and to address the uneven regional distribution of medical resources. Additionally, increasing access to quality primary community clinics may be a pro-poor policy to alleviate inequity in the use of outpatient care. Compared to outpatient services, policies protecting vulnerable populations need to pay more attention to the financing and design of inpatient services.


Assuntos
Assistência Ambulatorial/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Hospitalização/economia , Idoso , China , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade
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